Introduction
Tympanic membrane
(TM) retraction refers to the inward movement of
the TM from its usual location. This condition is
marked by partial collapse of the middle ear
spaces, affecting either the Pars Tensa (PT) or
Pars Flaccida (PF) of the tympanic membrane.[1]
Previously benign retractions can become active
over time, and larger retractions may accumulate
migrating epithelium. This accumulation can lead
to the formation of a cholesteatoma, which may
erode the ossicular chain or disrupt the middle
ear, ultimately resulting in hearing loss.
Otoscopic evidence of tympanic membrane
retractions is often regarded as an indicator of
disease progression and a marker of its
severity.[2] Therefore correct diagnosis and
management with regular follow up of TM retraction
pockets is essential.
Eustachian tube
dysfunction and weakening of the tympanic membrane
from otitis media with effusion are the two major
contributors to pathophysiology of retraction
pockets.[3] The point prevalence of PF and PT
retraction in children aged 5 to 16 years is
reported to range from 14% to 26% for PF
retractions and from 0.3% to 3.7% for PT
retractions.[4] The four stage classification of
Sade for pars tensa retraction [5] and the four
stage classification of Tos et al for pars
flaccida retraction [6] are currently clinically
most accepted classifications irrespective of age
and presence or absence of OME, although some
researchers have questioned the clinical
usefulness of these classifications.[7,8] In
Adults, retractions are seen in inactive squamous
chronic otitis media (COM) and hearing impairment
is often the only presentation.[9]
Otoscopy and
tympanometry are complementary tests that provide
distinct yet valuable clinical insights regarding
tympanic membrane retractions. Otoscopy provides a
visual assessment of the tympanic membrane's
appearance, while tympanometry measures the
mobility of the tympanic membrane and middle ear
function. Together, these tests help in assessing
the presence, severity, and impact of retractions
on ear health. Oto-endoscopy allows better
visualization of TM because of closer positioning
and better illumination and found significantly
better than tympanometry. It is time efficient,
can be used for uncooperative patients and
patients with a narrow ear canal.[10] Otoendoscopy
has gained significant popularity in recent years
for both diagnostic and surgical purposes.[11,12]
Compared to
traditional microscopic techniques, otoendoscopy
offers several advantages, including a wider and
magnified field of view, improved illumination,
and the ability to visualize the ear canal and
tympanic membrane from various angles. This
enhanced perspective allows for more detailed
examination and more precise surgical
interventions, ultimately improving patient
outcomes. Additionally, otoendoscopy serves as an
exceptional teaching tool due to its detailed and
dynamic imaging capabilities.[13.14] Recently,
several technical enhancements have been
introduced to otoendoscopy beyond standard white
light (WL) endoscopy, primarily through the use of
specific optical filters. For instance, the
Spectra A filter reduces red hues, improving the
contrast and visibility of structures by
minimizing the interference from red tones. On the
other hand, the Spectra B filter enhances the
green and blue spectral components, which can aid
in distinguishing subtle details and variations in
tissue color that may be critical for accurate
diagnosis and surgical precision. These
advancements allow for better visualization and
assessment of ear conditions.[15]
After an exhaustive
review of the available print and electronic
literature it was found that there have been
similar studies internationally but very limited
in the Indian scenario. Hence a cross sectional
descriptive study was designed with the aim to
clinically evaluate and grade tympanic membrane
retraction and to compare otoscopy and
otoendoscopy findings in different grades of
tympanic membrane retraction.
Materials and Methods
The study was
conducted in the Department of a tertiary care
teaching institute over a period of one year. The
patients attending for otorhinolaryngology
services of the institute, diagnosed as cases of
TM retractions were included in this study after a
written and informed consent statement from
patient and parent or legally authorized
representative in case of minor’s participant. The
study was started after the approval of the
protocol by the Institutional Ethics Committee
(XXXX/ETHIC/ decision number:94).
Patients with age
group below 6 years, TM perforation, history of
ear surgery, COM with complications and any
psychiatric disorder were excluded. Each patient
selected for the study underwent a thorough
medical history review and a comprehensive ear,
nose, and throat examination. Each of these
patients were graded clinically according to the
Sade and Tos system of classification for pars
tensa and pars flaccida retractions respectively
using pneumatic otoscope and otoendoscope.
Statistical testing
was performed using the Statistical Package for
the Social Sciences (SPSS) version 17. Continuous
variables are reported as mean ± standard
deviation (SD), while categorical variables are
presented as absolute numbers and percentages.
Before statistical analysis, data were assessed
for normality to ensure appropriate analytical
methods were applied. The Kruskal-Wallis test was
used for initial comparisons among multiple
groups, followed by paired comparisons with the
Mann-Whitney U test to evaluate differences
between specific groups. Categorical variables
were analyzed using the chi-square test. A p-value
of less than 0.05 was considered statistically
significant for all tests.
Results
A total of 5,076
patients who visited the otorhinolaryngology
department for otological services out of which
111 patients of tympanic membrane retraction were
included in this study. Of 10,152 ears that were
evaluated TM retractions were found in 190 ears,
an incidence rate of 0.018 in our study group. 79
(71.2%) patients had bilateral ear pathology
whereas 32 (28.8%) patients had unilateral
pathology making a total of 190 ears of 111
patients.
The median age was
found to be 32 years with a minimum-maximum age
ranging from 7-70 years with mean age of 32.45
years ± 15.20 years. 54 (48.6%) out of 111
patients were in the age group 21-40 years. Study
comprised of 48 (43.2%) females and 63 (56.8%)
males with the male-to-female ratio was 1.3:1.
Patients belonging to urban areas were 57 (51.4%)
as compared to 54 (48.6%) from rural areas.
Aural fullness was
the commonest symptom 127 (66.8%) of the 190 ears
followed by hearing loss in 108 (56.8%) ears.
Retractions were coincidentally found in 20
(10.5%) ears with no aural symptoms. History of
progressive hearing loss was present in 68 (62.9%)
out 108 ears with hearing loss. The duration of
hearing loss in our cases was less than or equal
to 1 month in 34 (32.7%) ears, less than 1 year in
68 (63.6%) ears. On examination of 190 ears,
isolated PT retraction (Figure- 1,2,3) was found
in 109 (57.3%) ears, isolated PF retraction
(Figure-4) seen in only 4 (2.1%) ears with the
remaining 77 (40.5%) ears having both PT and PF
tympanic membrane retractions.
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Figure
1: Right ear: Grade II PT retraction
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Figure
2: Right ear: Grade III PT retraction
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Figure
3: Left ear: Grade IV PT retraction |
Figure
4: Right ear: Grade IV PF retraction |
In total 186
(97.89%) of the 190 ears had PT retraction and 81
(42.6%) ears had PF retraction. The distribution
of pars tensa retractions on otoscopic
examination,there was no retraction, i.e., a
normal (Grade 0) PT in 6 (3.2%) of the ears, 110
(57.9 %) ears had Grade I retraction, 27 (14.2%)
ears had Grade II retraction, Grade III retraction
was seen in 20 (10.5%) ears with 27 (14.2%) ears
showing Grade IV retraction. Compared to this on
Otoendoscopy 4 (2.1%) ears had a normal PT, 105
(55.3%) ears had Grade I, 29 (15.3%) ears with
Grade II retraction, 23 (12.1%) ears had Grade III
retractions and Grade IV retractions were seen in
29 (15.3%) ears. (Figure-5) A cross-tabulation of
these findings revealed a significant relationship
(p<0.001) between otoscopy and otoendoscopy. A
difference in findings was seen in 23 (12.1%) ears
between otoscopy and otoendoscopy.
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Figure-5:
Distribution PT Grade on Otoscopy and
Otoendoscopy |
Figure-6:
Distribution PF Grade on Otoscopy and
Otoendoscopy |
The distribution of
PF retractions on otoscopic examination there was
no retraction, i.e., a normal (Grade 0) PF in 121
(63.7%) of the ears, 28 (14.7%) ears had Grade I
retraction, 25 (13.2%) ears had Grade II
retraction, Grade III retraction was seen in 13
(6.8%) ears with only 3 (1.6%) ears showing Grade
IV retraction. Compared to this, 109 (57.4%) ears
had a normal PF on otoendoscopy, 30 (15.8%) ears
had Grade I, 28 (14.7%) ears with Grade II
retraction, 16 (8.4%) ears had Grade III
retractions and Grade IV retractions were seen in
7 (3.7%) ears (Figure-6). A cross-tabulation of
these findings demonstrated a significant
relationship (p<0.001) between otoscopy and
otoendoscopy. Additionally, a cross-tabulation of
otoendoscopy findings revealed a significant
relationship (p<0.001) between PT and PF
retractions.
Discussion
A total of 111
patients of tympanic membrane retraction were
included in this study. 79 (71.2%) patients had
bilateral ear pathology whereas 32 (28.8%)
patients had unilateral pathology making a total
of 190 ears. In our study of 111 patients the
median age was found to be 32 years and 54 (48.6%)
patients in the age group 21-40 years. This
preponderance in young adults was also reported by
Grewal et al.[16 ] We found no substantial gender
predisposition with a male-to-female ratio was
1.3:1. Aural fullness was the commonest feature in
127 (66.8%) ears. Otalgia was present in 35
(18.4%) ears and tinnitus in 30 (15.8%) ears with
10% being asymptomatic ears. History was less than
1 year in 63.6% ears. A study reported mean length
of history of hearing problem in 1267 children to
be 13 months (SD=7.1).[2] Most children possibly
had longer fluctuating hearing loss that was
undetected.[1]
Mills in their study
stressed that despite few symptoms and incidental
detection, retraction pocket require regular
follow up to 3 months, since they do have
propensity to progress to cholesteatoma and cause
ossicular erosion and significant hearing
loss.[17] Borgstein et al emphasized the need for
re-examination for every 3 months for many years
children tend do show more aggressive course, as
do ears with higher degree of retraction at the
time of initial detection.[7] Given the need for
follow up of staging is required, a reliable
staging system is needed to ensure intra and inter
observer reliability.
Bilateral ear
pathology was seen in 79 (71.2%) patients perhaps
because 54 out 111 patients were from a rural
background with a consequent delay and inadequate
treatment of childhood OME. Childhood OME is often
initiating factor and retractions are known to
sometimes remain and progress after the resolution
of OME.[1] Additionally factors like ET cartilage
defects, Patulous ET (significant in adults and
adolescents), atopy and reflux, have been
postulated. We observed the TM by both otoscopy
and otoendoscopy and sought to compare the
clinical findings of TM colour, transparency,
mobility and retraction grade. A difference in
staging between otoscopy and otoendoscopy was seen
in 23 (12.1%) ears of PT retractions and 29
(15.3%) ears of PF retractions. A cross-tabulation
of these findings revealed a significant
relationship (p<0.001) between otoscopy and
otoendoscopy.
A close association
was observed between otoscopy and otoendoscopy
(p<0.001) for both PT and PF. We statistically
analyzed the results with a view of exploring
whether there was a significant association
between otoscopic and otoendoscopic results. One
of the aims of our study was to establish if
otoendoscopy was superior to otoscopy and whether
there was a need for further investigation like
microscopy in case where there was any significant
discrepancy in any particular grade of the
disease. Our p values suggest a significant
correlation exists. An-Suey et al. found that
pneumatic otoscopy failed in 2.5% (5/201) of
cases. The failures were attributed to factors
such as the narrowness of the external ear canals
and the presence of relatively long internal
hairs.[10]
Videotelescopy and
tympanometry accurately predicted myringotomy
outcomes in cases where pneumatic otoscopy failed.
However, due to the limited number of failures in
the study, further research is needed to determine
whether videotelescopy or tympanometry is
significantly superior to pneumatic
otoscopy.[10,18] Cross-tabulating otoendoscopy
findings revealed a significant relationship (p
<0.001) between PF and PT retraction. In our
study, 77 (95.1%) ears of the patients with PF
retractions also had involvement of PT which was
higher than 78% quoted by Tos.[6] It was also seen
that 109 (57.36%) of 186 ears with PT retraction
had a normal PF in contrast to the close
correlation between changes in PT and PF reported
by Sade, especially in ears in which effect of
prolonged low pressure on PT dominates.[19] We
found combined PT and PF retractions in 77 ears
(40.53%). This contrasts with another study that
reported a higher prevalence of retractions in
either PT or PF alone, rather than both
simultaneously.[2 ]Current study conducted in age
group7-70 years showed PF retraction in 81 (42.6
%) ears, PF retractions are more common in adults
than in children. Borgstein reported PF retraction
in only 4% of ears in his pediatric series which
is also corroborated by Bluestone and Klein.[20.
21]
Limitations of our
study was we did not study the etiology of
retractions in our study. We were also unable to
carry out eustachian tube function tests and
myringotomy in these patients which would have
aided in establishing the possible etiology and
comparing the sensitivity and specificity of
otoscopy and otoendoscopy.
Conclusion
It was thus
concluded that detailed examination using both
otoscope and otoendoscope is quintessential for
early detection and classification of tympanic
membrane retractions. Otoscopy and otoendoscopy
are useful aids for evaluating and monitoring the
clinical profile of TM retractions. The key
advantage of the videotelescopy used in this study
is its real-time magnification and clarity of the
eardrum image, which is displayed on a monitor.
This enhanced visualization allows for more
accurate assessment and diagnosis compared to
traditional methods. The acquisition of
large, clear, high-quality images enables precise
evaluation and documentation of ear structures,
facilitating accurate diagnosis and effective
treatment planning. The technique can be
seamlessly applied in clinical practice, research,
instructional settings, and medical trainee
supervision. An added benefit is that the visual
display can be shared in real-time with colleagues
or students, enhancing collaborative learning and
immediate feedback. Additionally, computer
manipulation with image-processing software allows
for digitized archiving, enabling future analysis
and facilitating the monitoring of retraction
pockets over time. These significant benefits
position otoendoscopy as a potential gold standard
for examining tympanic membrane (TM) retractions
in outpatient settings, particularly in referral
institutes where such facilities are readily
available.
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